MEDICATIONS USED IN SUBSTANCE USE TREATMENT AND RECOVERY

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1 MEDICATIONS USED IN SUBSTANCE USE TREATMENT AND RECOVERY Carl M. Dawson, M.S., MAC, LPC - National Drug Court Institute ( NDCI ) Washington, D. C. - The School of Professional Psychology at Forest Institute Springfield, Missouri ( )

2 OUTLINE THE USE OF MEDICATIONS IN TREATMENT KEEPING OUR PERSPECTIVE MEDICATIONS OF REFERENCE. SEVEN ( 7 ) NEUROTRANSMITTERS OF IMPORTANCE. THE USE OF ANTI DEPRESSANTS. ANTI ALCOHOL MEDICATIONS ANTI COCAINE MEDICATIONS. AN INTRODUCTION TO OPIOIDS ANTI OPIOID MEDICATIONS.

3 KEEPING OUR PERSPECTIVE IN TREATMENT EVERY INDIVIDUAL THAT ENTERS INTO THE PROCESS OF RECOVERY IS CURSED WITH KNOWING THAT THEY POSSESS ONE MORE RELAPSE... WHAT THEY DON T KNOW... IS HOW MANY MORE OPPORTUNITES, IF EVER, THEY WILL HAVE TO RECOVER! REMEMBER...

4 ... our primary goal during the early months of recovery is not to focus on the idea of long term sobriety, but to keep the person from relapsing. Relapse is and will always be our enemy. During early recovery, focus on teaching the individual(s) how not to relapse and what it will take for them to stay drug free long enough until they feel confident about not using, and experienced enough time to reestablish a new life without the use mood altering substances. THEREFORE...

5 ...THE COMPLETE ABSTANCE FROM THE USE OF ALL MOOD ALTERING SUBSTANCES, INCLUDING THE INDIVIDUALS LEAST DRUG OF CHOICE, SHOULD BE THE FUNDAMENTAL PHILOSOPHY OF EVERY EFFECTIVE RECOVERY AND RELAPSE PREVENTION PROGRAM. HOWEVER...

6 ... WE MUST KEEP IN MIND THAT CURRENTLY THERE ARE EFFECTIVE MEDICATIONS THAT ASSIST HEALTH CARE PROFESSIONALS IN TREATING PSYCHIATRIC DISORDERS, SLEEP DISORDERS, NEUROLOGICAL DISORDERS, AND PHYSICAL MEDICAL DISEASES. WE ARE IN PART AN CHEMICAL ORGANISM. FURTHERMORE...

7 ... WE CAN NOT IGNORE THAT SINCE 1966 SCIENTIFIC AND MEDICAL SOCIETIES HAS RESEARCHED SUBSTANCE USE AND HAS DETERMINED THAT CHEMICAL DEPENDENCY DISORDERS ARE A CONSEQUIENCE OF BIOLOGICAL, PSYCHOLOGICAL, PHYSICAL AND SOCIOLOGICAL FACTORS THUS, POSSESSING THAT SCIENTIFIC KNOWLEDGE AND CONVENTIONAL WISDOM... WE MUST ALL BE WILLING TO EMBRACE THE CURRENT UNDERSTANDING THAT WE ARE DEALING WITH A BIO CHEMICAL PSYCHOLOGICAL DISORDER... DEFINED BY A PROCESS... THAT BEGINS IN THE BRAIN. THEREFORE...

8 ... CONSIDER... THAT IN THE FUTURE, TREATMENT OF CHEMICAL DEPENDENCY DISORDERS WILL AND SHOULD INCLUDE THE PROPER BALANCE OF THERAPEUTIC INTERVENTIONS THAT INCLUDE, CONVENTIONAL COUNSELING TECHNIQUES, EDUCATION, PREVENTION, SELF HELP GROUPS, PSYCHOLOGY, MEDICINE, SPIRITUALITY AND CHEMISTRY.

9 THE COMMON NEURON

10

11 NEURONAL CHEMICAL COMMUNICATION

12 THE ACTIONS OF A COMMON NEURON

13 NEUROTRANSMITTERS INVOLVED IN CHEMICAL ABUSE AND DEPENDENCY

14 SEVEN ( 7 ) PRIMARY NEUROTRANSMITTERS INVOLVED IN SUBSTANCE ABUSE AND DEPENDENCY We are considered to possess Sixty ( 60 ) plus neurotransmitters / neuromodulators in the brain and nervous system. The Big Three ( 3 ) are the following : 1. Dopamine ( DA ) : Involved with pleasure, small and large motor movements and psychosis. 2. Serotonin ( 5ht ) : Involved with self - confidence, feelings of well - being and mood disorders. 3. Norepinephrine ( NE ) : Stimulates the brains fight or flight centers.

15 ANTI DEPESSANT MEDICATIONS AND THEIR USE IN SUBSTANCE USE DISORDERS

16 DESIGNER ANTI DEPRESSANT MEDICATIONS : THESE MEDICATIONS ARE SPECIFICALLY DESIGNED TO EFFECT EITHER SERIOTONIN ( 5HT ) OR NOREPINEPHRINE ( NE ) AND TO A LESSER EXTENT DOPAMINE ( DA ) NEUROTRANSMITTERS. THESE MEDICATIONS INCLUDE : 1. PROZAC ( 5HT ) 2. LEXAPRO ( 5HT ) 3. CELEXA ( 5HT ) 4. ZOLOFT ( 5HT ) 5. CYMBALTA ( 5HT & NE ) 6. WELLBUTRIN ( NE & DA ) THESE MEDICATIONS ARE EFFECTIVE FOR THE TREATMENT OF REACTIVE AND CLINICAL DEPRESSION. THESE MEDICATIONS HAVE BEEN FOUND TO BE EFFECTIVE IN TREATING SUBSTANCE ABUSE DISORDERS DUE TO THEIR INFLUENCE ON THE DOPAMINE ( DA ) SYSTEM.

17 NORMAL REUPTAKE OF DA, 5ht, NE

18 PSYCHIATRIC - ALCOHOL MOOD DISORDERS Higher than Normal Dopamine ( DA ) Normal Baseline Dopamine ( DA ) Below Normal Dopamine ( DA ) Depression Returns to Below Normal Dopamine ( DA ) Depression

19 ANTI ALCOHOL MEDICATIONS

20 THE ALCOHOL BREAKDOWN SEQUENCE ACETALALHIDE ADH IS VERY TOXIC TO THE BODY CO2 ALDH H2O ACETATE

21 ANTI ALCOHOL MEDICATIONS ANTABUSE : IS A MEDICINE DESIGNED TO STOP THE NORMAL BREAK DOWN OF ALCOHOL IN THE BODY. ANTABUSE : STOPS THE BREAKDOWN OF ALCOHOL AT THE ACETALDEHYDE STAGE. ACETALDEHYDE IS HIGHLY TOXIC TO THE BODY. DRINKING WHILE USING ANTABUSE WILL RESULT IN SIGNIFICANT PHYSICAL DISTRESS.

22 THE ALCOHOL BREAKDOWN SEQUENCE WITH ANTABUSE ADH ACETALALHIDE IS VERY TOXIC TO THE BODY AND WILL ACCUMULATE CAUSING A SEVERE TOXIC REACTIONS. CO2 H2O ACETATE ALDH

23 ANTI - ALCOHOL CRAVING MEDICATIONS

24 THREE ( 3 ) NEUROTRANSMITTERS INVOLVED IN ANTI ALCOHOL MEDICATIONS GABA : Sedates the over excited Brain, reduces anxiety, acts like a Sedative drug on the Brain. Glutamate : Activates the Under excited Brain, increases alertness, motivation to learn new information. Endorphins : Biological Pain Killers known as Opioids.

25 REGIONS IN THE BRAIN ASSOCIATED WITH CRAVINGS

26 ANTI ALCOHOL CONT. ACAMPROSATE ( CAMPRAL ) : IS DESIGNED TO QUICKLY RESTORE THE GLUTAMATE SYSTEM AFTER DRINKING. ALCOHOL WITHDRAWAL SYNDROME IS A HOMEOSTASIS FEED BACK RESPONSE INVOLVING AN EXCESSIVE RELEASE OF GLUTAMATE. ACAMPROSATE APPEARS TO DECREASE ALCOHOL CONSUMPTION, WHILE... NALTREXONE IS MORE EFFECTIVE IN MAINTAINING ABSTINENCE.

27 CAMPARAL EFFECTS THE GLUTAMATE CYCLE ( GLUTAMATE ) ( GABA / ENDORPHINS )

28 ANTI ALCOHOL CONT. NALTREXONE ( VIVITROL OR ReVia ) : A FULL OPIOID ANTAGONISTS ( BLOCKER ). NALTREXONE IS DESIGNED TO BLOCK THE RAPID RELEASE OF ENDORPHINS THAT SOME INDIVIDUALS REPORT EXPERIENCING WHEN CONSUMING A DRINK. BLOCKING THE ENDORPHINS RUSH REDUCES THE DESIRED EFFECTS OF ALCOHOL FOR APPROXIMATELY ( 30 ) DAYS.

29 VIVITROL EFFECTS THE GABA - ENDORPHINS CYCLES (GLUTAMATE) ( GABA / ENDORPHINS )

30 ANTI COCAINE MEDICATIONS DEVELOPED BY DR. THOMAS KOSTEN BAYLOR MEDICAL SCHOOL, HOUSTON, TX.

31 REUPTAKE INHIBITION ( COCAINE )

32 COCAINE S MOLECULES ARE UNDECTABLE BY THE BODY S AUTOIMMUNE SYSTEM

33 DR. KOSNEN S CHEMICAL FINDS AND ATTACHES TO THE COCAINE MOLECULE ALLOWING THE AUTOIMMMUNE SYSTEM TO THEN IDENTIFY AND DISABLE THE MOLECULE

34 AN INTRODUCTION TO OPIOID SUBSTANCES

35 What is an Agonist and an Antagonistic substance. An introduction to Opioid substances and how they impact the nervous system. Three ( 3 ) Therapeutic Objectives when treating Opioid abuse and dependence. The Therapeutic Dilemma when treating Opioid abuse and dependence. The Use of Medications In the Treatment of Opioid abuse, dependency and recovery. Methadone. Buprenophrine ( Subutex ). Buprenophrine and Naloxone ( Suboxone ). REGIONS OF BRAIN

36 FULL AGONIST ACCEPTS ALL OPIOID NEUROTRANSMITTERS

37 FULL ANTAGONIST REJECTS ALL OPIOID NEUROTRANSMITTERS

38 PARTIAL AGONIST ACCEPTS SOME & ANTAGONIST REJECTS OTHERS

39 HYPOTHETICAL DOSE RESPONSE CURVE FOR A FULL and PARTICAL Mu OPIOID AGONISTS INCREASING OPIOID EFFECTS FULL OPIOID AGONIST ( METHADONE ) ( CELILING ) PARTICAL OPIOID AGONIST ANITGONIST ( BUPRENORPHINE ) INCREASING ACUTE OPIOID DOSE

40 OPIOID DRUGS ARE CONSIDERED LOOK ALIKE NEUROTRANSMITTERS THE HUMAN BODY PRODUCES IT S OWN NATURAL PAIN FIGHTING SUBSTANCES CALLED ENDOGENOUS ( CREATED FROM THE INSIDE ) OPIOIDS. SYNTHETHIC OPIOIDS ARE MANUFACTERED SUBSTANCES CREATED IN A LABORATORY AND TAILORED TO MIMIC THE BODY S OWN ENDOGENOUS OPIOIDS.

41 THE THREE ( 3 ) PRIMARY OPIOID RECEPTORS Mu RECEPTORS : THE PRIMARY OPIOID RECEPTORS THAT HAVE THE STRONGEST ATTRACTION TO OPIOID SUBSTANCES... AND TRIGGER THE RELEASE OF PAIN AND PLEASURE PRODUCING CHEMICALS IN THE BRAIN. DELTA AND KAPPA OPIOID RECEPTORS ARE LESS ATTRACTIONED TO OPIOID SUBSTANCES IN THE BRAIN.

42 THE CENTRAL NERVOUS SYSTEM ( CNS ) CONSISTS OF THE BRAIN AND THE SPINAL CORD. THE GREATEST AMOUNT OF THE BODY S OPIOID ( Mu ) RECEPTORS ARE LOCATED THROUGHOUT THE BRAIN... LESS IN THE SPINAL CORD. FULL AGONIST RECEPTORS

43 OUR NERVOUS SYSTEM ( N.S. ) HAS A DETERMINED NUMBER OF OPIOID RECEPTORS, DESIGNED TO PROTECT US FROM PAIN.

44 HOWEVER, WHEN THE N.S. RECEIVES A GREATER THAN NORMAL AMOUNT OF OPIOIDS, OVER A PROLONGED PERIOD OF TIME, THE N.S. WILL NATURALLY REDUCE THE NUMBER OF RECEPTORS AVAILABLE IN ORDER TO LIMIT THE AMOUNT OF PLEASURE RELEASING CHEMICALS BEING ABSORBED BY THE BODY AND BRAIN. DOWN REG

45 THIS IS REFERRED TO AS DOWN REGULATION

46 THE PROCESS OF THE BRAIN DOWN REGULATING IT S SELF MAY RESULT IN EITHER SHORT - TERM ( TEMPORARY ) ABUSE SYMPTOMS OR LONG -TERM ( CHRONIC ) DEPENDENCY NEURONAL CHANGES. BUPRENOPHINE

47 THREE ( 3 ) THERAPEUTIC OBJECTIVES TO REMEMBER WHEN TREATING THE OPIOID DEPENDENT INDIVIDUAL...

48 ( FIRST ( 1 ST ) OBJECTIVE ) STOP THE ILLICIT DRUG USE! ( SECOND ( 2 ND ) OBJECTIVE ) ABSTAIN FROM THE USE OF ALL DRUGS... INCLUDING ALCOHOL!

49 THIRD ( 3 RD ) OBJECTIVE TO ELIMINATE THE OBSTICALES THAT LEAD TO RELAPSE! THAT INCLUDES CHANGING PEOPLE, PLACES, THINGS AND LIMITING CRAVINGS.

50 THE THERAPEUTIC DILEMMA SINCE OPIOID DEPENDENCE IS A MEDICAL / PHYSICAL DISORDER IMPACTING THE BRAIN... YOUR THERAPEUTIC DILEMMA IS...

51 ... WILL THE INDIVIDUAL S N.S. REBOUND ONCE THE OPIOID DRUGS ARE DISCONTINUED... OR HAS THE LONG -TERM USE OF OPIOID DRUGS CREATED A PERMINATE ( CHRONIC ) CHANGE IN THE BRAIN, REQUIRING THE USE OF OPIOID REPLACEMENT MEDICATIONS IN ORDER TO BE ABLE TO FUNCTION WITHOUT PAIN OR PHYSICAL CRAVINGS? THE FOLLOWING IS WHAT YOU MUST CONSIDER...

52 ... ASSUMING THAT THE BODY WILL NATURALLY REBOUND AND RETURN TO NORMAL... THE USE OF OPIOID REPLACEMENT MEDICATIONS MAY BE COMPLETELY UNNECESSARY... HOWEVER, IN LIMITED CIRCUMSTANCES OPIOID REPLACEMENT MEDICATIONS MAYBE AN IMPORTANT SHORT - TERM THERAPERUTIC OPTION, IN CONJUNCTION WITH CONVENTIONAL TREATMENT. IN THIS EVENT, OUR THERAPEUTIC MOTIVE WILL BE TO EVENTUALLY TAPER - DOWN AND DISCONTINUE THE USE OF OPIOID REPLACEMENT MEDICATIONS SAFELY OVER TIME.

53 HOWEVER... IF AN INDIVIDUALS CONTINUED AND CHRONIC USE OF OPIOID SUBSTANCES HAS PRODUCED NEUROLOGICAL CHANGES THAT HAS RESULTED IN OPIOID RECEPTOR DOWN REGULATION, THAN THE USE OF OPIOID REPLACEMENT MAINTANENCE MEDICATIONS MAY NEEDED IN ORDER TO AVOID RELAPSE AND THE EVENTUAL RETURN TO ILLICIT DRUG USING BEHAVIORS. THE FOLLOWING MEDICATIONS ARE CURRENTLY BEING USED IN LONG TERM OPIOID DEPENDENCE TREATMENT : 1. METHADONE 2. SUBUTEX 3. SUBOXONE

54 METHADONE MAINTANENCE ( HARM REDUCTION ) ( ANTI CRAVING ) THERAPY

55 METHADONE TREATMENT IS FREQUENTLY REFERRED TO AS MAINTENANCE OR HARM REDUCTION THERAPY. METHADONE IS A LESS POWERFUL OPIOID MEDICATION THAT IS USED IN PLACE OF A MORE POWERFUL OPIOID SUBSTANCE ( HEROIN ). METHADONE IS A LONG ACTING OPIOID SUBSTANCE. METHADONE USE WILL TYPICALLY BLOCK OPIOID WITHDRAWAL SYMPTOMS FOR TWENTY FOUR ( 24 ) TO SEVENTY TWO ( 72 ) HOURS. ALTHOUGH LESS POWERFUL THAN HEROIN... METHADONE DOES CREATE A PHYSICAL DEPENDENCY AND CAN BE ABUSED AND DIVERTED.

56 BUPRENOPHINE ANTI OPIOID, ANTI - CRAVING MEDICATIONS ( SUBUTEX vs. SUBOXONE )

57 WHEN USED CORRECTLY, SUBUTEX AND SUBOXONE EMPLOY BUPRENOPHINE A HIGHLY STUBBORN AND LESS PHYSICALLY DEPENDENT PRODUCING OPIOID. BUPRENOPHINE, IS DESIGNED TO REPLENISH THE BODY AND BRAIN WITH NECESSARY PAIN FIGHTING SUBSTANCES, LOST DUE TO CHRONIC NEURONAL CHANGES ( DOWN REGULATION OF THE Mu RECEPTORS ) AND REDUCING THE DRUG S CRAVING CYCLES.

58 SUBUTEX THE MEDICATION SUBUTEX IS STRAIGHT BUPRENOPHINE... AND CAN BE ABUSED BY SIMPLY TAKING MORE THAN RECOMMENDED OR... BY COMBINING SUBTEX WITH OTHER OPIOIDS OR CENTRALLY ACTIVATING DEPRESSING DRUGS.

59 SUBUTEX ( BUPRENOPHRINE ONLY ) SUBUTEX CAN BE PRESCRIBED IN 2 mg and 8 mg DOSES. INTRODUCED INTO THE BODY VIA SUBLINGUAL ADMINISTRATION ( Under the Tongue ).

60 SUBOXONE THE MEDICATION CALLED SUBOXONE COMBINES BUPRENORPHINE WITH NALOXONE. ADDING NALOXONE TO BUPRENORPHINE REDUCES THE ABUSE OF OTHER OPIOID DRUGS, BY BLOCKING THEIR CHEMICAL ADMISSION INTO THE KAPPA OPIOID RECEPTORS. COMBINING NALOXONE WITH BUPRENOPRPHINE PREVENTS INTENTIONAL ABUSE, 1. EITHER BY OVER USE, 2. DIVERSIONARY TACTICS OR THROUGH ( I.V. ) INJECTIONS.

61 SUBOXONE ( BUPRENORPHINE WITH NALOXONE ). SUBOXONE CAN BE PRESCRIBED IN TWO ( 2 ) DOSES : (1). 2 mg of buprenorphine and 0.5 mg of naloxone. (2). 8 mg of buprenorphine and 2 mg of naloxone. INTRODUCED INTO THE BODY VIA SUBLINGUAL ADMINISTRATION ( Under the Tongue ).

62 HOWEVER, WHEN SUBOXONE IS BEING ABUSED, DIVERTED, OR COMBINDED WITH OTHER OPIOID DRUGS... THE ANTAGNONIST BLOCKING AGENT NALOXONE BECOMES ACTIVATED, REPLACING BUPRENOPHINE... RESULTING IN AN PRECIPITATED OPIOID WITHDRAWAL. WITHDRAWAL

63 THEREFORE, SUBOXONE CAN NOT BE ABUSED... OR DIVERTED WITHOUT CREATING AN IMMEDIATE PHYSICAL WITHDRAWAL. WITHDRAWAL

64 THE ADDITION OF NALOXONE ALSO MAKES SUBOXONE SAFE FROM POTENTIAL DRUG OVERDOSING. HOWEVER, THE COMBINED USE OF ALCOHOL OR ANTI -ANXIETY AGENTS ( BENZODIAZEPINES ) WITH SUBOXONE IS DANGEROUS AND WILL INCREASE THE RISK OF DRUG OVERDOSE!!! OVERDOSE

65 OUR GREATEST ENEMY IN FIGHTING SUBSTANCE USE AND RELAPSE... IS NOT THE DRUG... BUT THE PERSON S REFUSAL TO FACE THE TRUTH ABOUT WHAT THE DRUG IS DOING TO THEM... OUR REAL ENEMY IS DENIAL! REMEMBER... KNOWLEDGE IS POWER!

66 CONTACT INFORMATION : CARL M. DAWSON, M.S., MAC, LPC 1320 E. KINGSLEY SUITE A SPRINGFIELD, MO ( )

67 References and Suggested Readings U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment TREATMENT IMPROVEMENT PROTOCOL (TIP) SERIES Rockwall II, 5600 Fishers Lane Rockville, MD 20857

68 American Psychiatric Association. (2000 ). Diagnostic and statistical manual of mental disorders (4 th ed). Washington, DC: American Psychiatric Association. Buelow, G., Herbert Suzanne (1995). Counselor s Resource on Psychiatric Medications, Issues of Treatment and Referral. Brooks/Cole Publishing Co., Pacific Grove, Ca. Buprenophine.samhsa.gov Galanter, M., Kleber, H. ( 2008). Textbook of Substance Abuse Treatment. 4 th ed., American Psychiatric Publishing, Inc., Washington, D.C.

69 National Institute on Drug Abuse ( NIDA). Selected Prescription Drugs with Potential for Abuse, and Preventing and Recognizing Prescription Drug Abuse, and Prescription and Over-the-Counter Medications Stahl, S.M. (2003), Essential Psychopharmacology, Neuroscientific Basis and Practical Applications (2 nd ed). Cambridge University Press. Strain, E.C., Stizer M.L. (eds): The Treatment of Opioid Dependence. Baltimore, MD, Johns hopkins University Press, 2006, pp Erickson, C., ( 2007), The Science of Addiction. W.W. Norton and Company, New York, London. Suboxone.com

70 Kinney, J., ( 2003 ) Loosening the Grip : A Handbook of Alcohol Information. Seventh Ed., McGraw Hill, New York, N.Y.. Ray, O., Ksir, C., ( 2004 ) Drugs, Society, and Human Behavior. Tenth Ed., McGraw Hill, New York, N.Y..

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